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Standard Medical History Statement

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The Standard Medical History Statement is to be used when evidence of insurability is required. Online or printable PDF options are available:

Choose Online

By completing your Standard Medical History Statement online, you will receive a decision much faster than completing the printable PDF form below.  The process usually takes between 10 and 20 minutes.  However, depending on your health history, it may take up to 30 minutes to complete. For the purpose of completing the Standard Medical History Statement, please note the MOSERS Group Life Policy Number is 604201.

Choose Mail

Print and submit your Standard Medical History Statement by mail. Your application will be reviewed by The Standard and you will receive a decision in 30-90 days after all necessary information is received. You will receive much faster service if you submit this form online rather than via mail.

Missouri State Employees' Retirement System
Address: 907 Wildwood Dr., Jefferson City, MO 65102 Phone: 800.827.1063 URL: Email: Founded On: September 1, 1957